July 29, 2016 | Bryan LeBude, MD
Education

In addition to serving as program director for the cardiovascular disease fellowship at MedStar Washington Hospital Center (MWHC) and Georgetown University Hospital, Gaby Weissman, MD, FACC is co-director of the advanced cardiac imaging fellowship at MWHC and the National Institutes of Health (NIH).

Bryan LeBude, MD recently sat down with Weissman to discuss his experiences as a multimodality cardiovascular imaging expert and the future of imaging training for the cardiology fellow.

What is your training background and why did you choose a career in multimodality imaging?

I feel that much of my path was guided by serendipity rather than planned course. I entered medicine residency without a definitive plan for the future. My first rotation as an intern in the cardiac care unit (CCU) convinced me to pursue a career in cardiology. I ended up finding a mentor and pursuing research projects involving cardiac biomechanics and myocardial strain. It was this relationship and these projects that sparked my interest in cardiovascular imaging. I then was able to obtain training in echocardiography and nuclear cardiology during my general fellowship, followed by a one year imaging fellowship in cardiac CT and MRI. Throughout my training I found that it was my mentorship relationships that helped me figure out what the right path would be.

What are some educational advantages of training in a variety of imaging modalities (including CCT and CMRI) during general cardiology fellowship, particularly for the fellows who do not plan on making formal interpretation of these studies a part of their career?

I think that imaging training in general cardiology programs presents important challenges for fellows. There is wide variation in the availability of imaging training. Echocardiography and nuclear cardiology form the base of cardiac imaging and are generally available in all training programs. Nonetheless, even in these disciplines there is a significant heterogeneity within programs (e.g., the availability of PET imaging, participation in intra-operative and interventional echocardiography, etc.). The experiences available for trainees in CT and MRI are probably even more varied across programs. As such, I think that a fellow needs to be quite thoughtful about their goals and how to have those goals supported during their training.

Every fellow should strive to achieve a sufficient level of familiarity with each technique to understand its place in the care of the cardiovascular patient. As an example, I usually find that fellows view MRI as a somewhat mysterious, expensive and complex test both for the patient as well as the physician. Therefore, they usually shy away from its use in situations where it might be appropriate. By achieving level I training in cardiac MRI (CMR), the trainee has a far better sense of the relative advantages and disadvantages of the technique. This tends to make it much more understandable and approachable. It is the familiarity with the technique and, therefore, the comfort level in using it when appropriate that forms the basis of using the proper test, for the proper indication, for the proper patient (the mantra of multimodality imaging).

With the release of the ACC Core Cardiovascular Training Statement (COCATS 4), what are the ways in which cardiology training programs are changing their imaging curriculum for the general fellow?

I can’t answer this question globally. I will comment on how we’ve been thinking about this in our program. For me, the most obvious changes have been in regards to echocardiography and the added emphasis on multimodality imaging. I think that both of these points are correct as these are trends that we see in our own institution. The centrality of echocardiography as a versatile and available imaging modality is clear to all of us as we take care of our patients across the entire spectrum of cardiovascular care.  

Secondly, the continuing growth within imaging and the rapid accumulation of data has led to a challenge as to what should be the baseline knowledge that each fellow obtains and how to fit that into a busy three years. I think that COCATS tried to address the tensions inherent in this situation as have some very nice editorials written by thought leaders within the ACC Imaging Council. For us, we are starting down the path of offering multimodality imaging rotations and trying to think about how to bring imaging modalities out of their silos (instead of an echo month, make some of the months “imaging months”). This is a significant challenge as the workflow in the labs and for the faculty is not designed to make this easily translatable into the real world. This is in stark contrast as to how radiology training is done.  If one thinks about a “neuroradiology” rotation, one assumes that CT and MRI would all be used during this rotation. However, in cardiac imaging we usually silo rotations by imaging technique. In our own institution, we are far from having answered this question, but it is part of our thinking as we make plans to move forward.  

How can cardiology fellowships effectively embrace competency-based learning in their imaging rotations?

In many ways, COCATS 4 and related documents from the imaging societies have made this task easier. There are very reasonable lists of core competencies listed in COCATS 4 that can be used by fellows and programs to make sure that the broad spectrum of competencies is being taught in imaging. Overall with changes from theAccreditation Council for Graduate Medical Education (ACGME) and in COCATS, there is an ongoing emphasis on competency. This continues to push programs to move away from numbers and to move to judging competency. I make this a part of my discussion with trainees in each semi-annual meeting. I try to step back from the numbers and discuss the fellow’s degree of comfort and competency in each subject matter. It is important for imaging section directors to use these competencies to evaluate fellows and provide feedback that is tied into these core competencies.  

Over the next decade, how do you envision advanced imaging training evolving?

This is the million dollar question. As a non-accredited fellowship, imaging has faced challenges in providing advanced training. There is heterogeneity in skills for graduates from general programs, in the type of training offered by advanced imaging programs, and in funding availability. In addition, historically there has not been a central database of these programs. I believe there is growing recognition of the importance of expert imagers to supplement the general imagers. Overall, the trend has been in the direction of a greater numbers of programs that offer a variety of experiences. In general in cardiology we strive for standardization. I am not sure that the future of advanced imaging training will go in that direction. I think that having programs that play to their strengths and, therefore, allow fellows to choose the path that best fits their interests may be the best answer. Advanced cardiac imaging is a very big umbrella with many different elements encompassed by it. Variety here may play to the advantage of all.

How does the current job market value the role of cardiologists trained in advanced imaging modalities, and in what direction do you predict this moving in the near future?

It is important to view the answer to the previous question in the light of this question. There is a tremendous amount of anxiety related to this question amongst trainees as everyone wants a great job and preferably a job that meets their needs both for their careers and their personal lives. I have no crystal ball here, but I believe that the following points are important. Firstly, I always tell trainees to pursue their passions and not plan based on a current job market, as that will forever be in evolution. Having said that, I really do think that we need to acquire more data to answer this question as the current knowledge base is scant. This will help fellows and programs think about how to frame their imaging training. This is where our societies such as the ACC and its councils can play a leading role. Lastly, the future of imaging is bright. It is a critical tool in our care of patients and with the emphasis of imaging research shifting to answering the question of how to use the right test in the right circumstance to change therapy and patient outcomes, one imagines that imaging will continue to play an important role in cardiology.   

What advice do you have for early first year fellows who may be interested in pursuing advanced imaging training?

Find a mentor. This person can be invaluable in many ways. They can help you frame the right questions. So much depends on the long term goals of the trainee, but often first years are busy trying to learn the basics of clinical cardiology and have little experience in cardiac imaging. A good mentor can help a fellow gain a better understanding of what a career in cardiac imaging would look like and how to take the initial steps in getting there. It is never too early to start thinking about this. The three years of cardiology fellowships pass by more quickly than most fellows realize, particularly while in the midst of their first year, and getting an early start with a mentor will serve the trainee in good stead.  

View the Advanced Imaging Training Program Database compiled by ACC’s Cardiovascular Imaging Section for more information on available training programs.

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This article was authored by Bryan LeBude, MD, a cardiology fellow at MedStar Washington Hospital Center and Georgetown University Hospital and a member of the Fellows in Training Section Leadership Council.